Presentation on theme: "OBJECTIVES NOT TO BE A NEPHROLOGIST"— Presentation transcript:
1 OBJECTIVES NOT TO BE A NEPHROLOGIST TO UNDERSTAND LUPUS NEPHRITIS AS A PRIMARY CARE PHYSICIAN .
2 OBJECTIVES Define nephrotic syndrome and glomerulonephritis Identify the Diagnostic criteria for SLEAntibodies markers in SLEPrognostic markers in SLEClassification of lupus nephritisIndications and contraindications of renal biopsyCommon side effects of medicine used in lupus nephritis
4 FOCAL NEPHRITICDIFFUSE NEPHRITICURINALYSISRed cells ( usually dysmorphic )Red cell castMild proteinuria (<1.5gm /day)Findings of more severe disease are usually absentURINALYSISSimilar to focal disease but heavy proteinuria (which may be in nephrotic range)EdemaHypertension+ Renal Insufficiency
9 Why did he order anti-dsDNA and anti-SM antibody? What is the role of complement level in lupus nephritis?
10 Serologic testANA's are a highly sensitive screen for SLE, being found in more than 90% of untreated patients, but they are not specific for SLE.anti-dsDNA are a more specific but less sensitive marker of SLE and are found in almost three fourths of untreated patients with active SLE(97% specificity).Titers of anti-dsDNA antibodies often fluctuate with disease activity.Anti-Sm antibodies, although very specific for SLE are found in only about 25% of lupus patients.
11 MONITORING CLINICAL DISEASE There is controversy regarding the value of a declining C3 and C4 level and a rising anti-DNA antibody titer in predicting a clinical flare of SLE or active renal disease.clearly these are the most widely used serologic tests to monitor SLE activity.Nonspecific:ESR /CRPCOURSE OF LUPUS NEPHRITIS EXTREMELY VARIED
12 SO IF A PATIENT HAS POSITIVE SEROLOGIC MARKERS FOR LUPUS WHICH CORRELATE WITH CLINICAL FINDINGS DO THEY STILL NEED A RENAL BIOPSY ? AND WHY?
14 CLASSIFICATION OF LUPUS NEPHRITIS CLASS I (Minimal Mesangial lupus Nephritis)CLASS II(Mesangial Proliferative Lupus Nephritis)CLASS III(focal lupus nephritis)CLASS IV (diffuse Lupus Nephritis )CLASS V (membranous lupus nephritis )CLASSVI (Advanced sclerosing lupus nephritis)
15 International Society of Nephrology/Renal Pathology Society (2003) Classification of Lupus Nephritis Class I Minimal mesangial LNClass II Mesangial proliferative LNClass III Focal LN* (<50% of glomeruli) III (A): Active lesions III (A/C): Active and chronic lesions III (C): Chronic lesionsClass IV Diffuse LN* (≥50% of glomeruli) Diffuse segmental (IV-S) or global (IV-γ) LN IV (A): Active lesions IV (A/C): Active and chronic lesions IV (C): Chronic lesionsClass V[†] Membranous LNClass VI Advanced sclerosing LN (≥90% globally sclerosed glomeruli without residual activity) .
16 Indications and contraindications of Renal Biopsy Persistent proteinuria (especially if >3.5gm/24hrs) not due to diabetes.Persistent glomerular hematuria(especially if accompained by RBC cast)Unexplained acute renal failure
17 RENAL BIOPSY CONTRAINDICATIONS: Coagulation Disorders Thrombocytopenia Uremic Platelet Dysfunction(relative contraindication)Uncontrolled hypertension(relative risk, maintain B.P<140/90)Solitary Kidney (open biopsy is procedure of choice)Advanced age and Pregnancy are NOT a contraindication
20 Side effects of medication . Cyclophosphamide:Pancytopenia (to check cbc every two weeks)Predispose to infection by bonemarrow depressionPremature amenorrhea,Permanent infertilityIncreases the risk of malignancyBladder toxicityHyponatremia due to SIADH
21 Mycophenolate mofetil (MMF) It is substantially more expensive then other drugsCytopenias: cbc first 2 weeks then every 6 weeksAssociation with developing CNS lymphoma.Antacids and Iron Supplements decrease absorption of MMF